Survey

KYC

Title:

First Name*:

Middle Name:

Last Name*:

Passport or Identity Card No.*:

Passport Expiry date*:

Country of issue*:

Phone number*:

Fax number:

Email address*:

Country of permanent residence*:

Nationality*:

Date of Birth*:

Place of Birth*:

Gender:

Marital Status:

Taxable Residence

Are you a United States Resident for Tax purposes:

Yes

Are you a United States Citizen:

Yes

Jurisdiction(s) for Tax purposes*:

Tax Identification Number (TIN)*:

Are you Politically Exposed or associated to any Political Person:

Yes

If Yes, please give details::

Occupation

Employer's Name:

Employer’s Business Address:

Employer’s Phone:

Employer’s Website:

Permanent Physical Address*

Street name & number:

Flat:

Area:

Postal code:

City:

Country:

Mailing Address (if different from the Permanent Address)*

Street name & number:

Flat:

Area:

Postal code:

City:

Country:

Telephone Number*

Home:

Work:

Mobile:

Fax:

Email Address*

Personal:

Work:

Preferred Language of Communication*:

General Terms

I hereby confirm that the information given above is true, correct and complete and you are hereby authorized to use this information for all services offered and for which I may apply from time to time and for all the services offered in the future.
Change of data For any changes in the data given above, I have the obligation to notify the company the soonest possible and I acknowledge that the company is not liable for any wrong data, or for the non-prompt amendment of data which I have omitted or neglected to send and to inform the company.
Know Your Client documentation Please attach to this application form, where applicable, the following documents:
- Color Copy of Identity Card or Passport
- Copy of a recent Utility bill (e.g. of electricity or telephone, or other document to the satisfaction of the Company evidencing the permanent residence of the Customer - maximum 6 months old).
- Recent bank statement if applicable (maximum 6 months old)

*The above documents are not exhaustive and the Company may require additional documents where this shall be deemed necessary.

I hereby declare and confirm that these are true and correct and that I have not withheld any relevant or substantial information.

I confirm that I have delivered whatever is required in accordance with point 3 above and that such are original and authentic and content is true and accurate.

Client name:

Date:

Signature:

Color Copy of Identity Card or Passport:

Copy of a recent Utility bill:

Recent bank statement if applicable (maximum 6 months old):